To the Editor,
We have read the article by Gerede et al. (1) recently published in the Anatolian Journal of Cardiology 2016; 16: 772-7 entitled “Use of strain and strain rate echocardiographic imaging to predict the progression of mitral stenosis: a 5-year follow-up study” with a great interest. In this study, the authors evaluated the left ventricu-lar global longitudinal strain (GLS) and strain rate (GLSR) in mitral valve stenosis (MS) and concluded that GLS and GLSR might be used as predictors of MS progression. There are some limitations of the present study. No detailed information was provided regard-ing the volume measurements of the cardiac chambers, presence of mitral regurgitation, assessment of the regional strain, and cor-relations of the deformation parameters with other comprehensive echocardiographic measures. There was no control group, which made it difficult to draw a conclusion. It would have been interest-ing to see the changes in the deformation measures over time if the investigators have measured GLS/GLSR at the end of the study.
Left ventricular dysfunction can be observed in MS (2, 3). Different mechanisms behind this association have been pos-tulated. Increased pressure gradient and decreased blood flow between the left atrium and the left ventricle caused by mitral inflow obstruction are mechanisms that result in underfilled left ventricle. In rheumatic MS, there might also be a direct effect of the rheumatic fever causing chronic myocardial inflammation and extended involvement of the subvalvular apparatus leading to a subsequent scarring. Regional strain analysis has also con-firmed this. Basal myocardium that is closer to valvular structures displays lower strain measurements, whereas the strain of the apical myocardium is more preserved (4). Left ventricular dyssyn-chrony is another contributing factor, likely due to involvement of the myocardium heterogeneously (2). Left ventricular dysfunction is reversible and tends to improve after balloon valvuloplasty as shown in previous studies (4, 5). However, even after the inter-vention, GLS was lower in the study group compared to controls, confirming the fact that there is still affected myocardium despite removing the obstruction, which suggests that both hemodynam-ic and myocardial factors contribute to the process (4).
The question is what would the clinical impact be if we use GLS/GLSR as predictors of MS progression? Would they be the indicators of early valvular intervention? Can we prevent myo-cardial damage if we start screening earlier and how often should we screen for myocardial dysfunction? Apparently, we need larger prospective studies to answer these questions. Uyanga Batnyam, Esra Gücük İpek
University of Central Florida College of Medicine HCA GME Consortium Internal Medicine Residency Program; Orlando-FL-USA
References
1. Gerede DM, Ongun A, Tulunay Kaya C, Acıbuca A, Özyüncü N, Erol Ç. Use of strain and strain rate echocardiographic imaging to pre-dict the progression of mitral stenosis: a 5-year follow-up study the progression of mitral stenosis: a 5-year follow-up study. Anatol J Cardiol 2016; 16: 772-7.
2. Güven S, Şen T, Tüfekçioğlu O, Gücük E, Uygur B, Kahraman E. Eva- luation of left ventricular systolic function with pulsed wave tissue Doppler in rheumatic mitral stenosis. Cardiol J 2014; 21: 33-8. 3. Özdemir AO, Kaya CT, Özcan OU, Özdöl C, Candemir B, Turhan S, et
al. Prediction of subclinical left ventricular dysfunction with longi-tudinal two-dimensional strain and strain rate imaging in patients with mitral stenosis. Int J Cardiovasc Imaging 2010; 26: 397-404. 4. Roushdy AM, Raafat SS, Shams KA, El-Sayed MH. Immediate and
short-term effect of balloon mitral valvuloplasty on global and re-gional biventricular function: a two-dimensional strain echocardio-graphic study. Eur Heart J Cardiovasc Imaging 2016; 17: 316-25. 5. Sengupta SP, Amaki M, Bansal M, Fulwani M, Washimkar S,
Hofs-tra L, et al. Effects of percutaneous balloon miHofs-tral valvuloplasty on left ventricular deformation in patients with isolated severe mitral stenosis: a speckle-tracking strain echocardiographic study. J Am Soc Echocardiogr 2014; 27: 639-47. Crossref
Address for Correspondence: Dr. Esra Gücük İpek University of Central Florida College of Medicine HCA GME Consortium Internal Medicine
Residency Program, Orlando-FL-US
Phone: 001- 321-697-1730 E-mail: esragucuk@hotmail.com
©Copyright 2017 by Turkish Society of Cardiology - Available online at www.anatoljcardiol.com
DOI:10.14744/AnatolJCardiol.2017.7635
Author`s Reply
To the Editor,
We thank the authors et al. (1) for their important comments to our paper entitled “Use of strain and strain rate echocardio-graphic imaging to predict the progression of mitral stenosis: a 5-year follow-up study” published in the Anatolian Journal of Cardiology 2016; 16: 772-7.
As you mentioned, we have not provided some data in the text, for example the volume measurements. There is no data re-garding the volume measurements in the text because we aimed to compare routine measurements taken in our laboratory. We routinely do not take volume measurements; therefore, we only provided information regarding the dimensions of the chambers. Similarly, we did not mention the degree of mitral regurgitation because we only included patients with isolated mitral stenosis. No patients with moderate or severe MR were included in our study; therefore, we did not mention this data in the text.
You have mentioned that there was no control group and GLS/ GLSR was not measured at the end of the study. However, we have mentioned this as a study limitation. The use of GLS/GLSR as a predictor of MS progression can be helpful to decide the frequency of control visits and to plan optimal management of
Anatol J Cardiol 2017; 17: 248-54 Letters to the Editor
